TNF Blockers as First-Line Therapy for Psoriatic Disease



Mark Lebwohl, MD: Let’s talk about the other agents. What about tumor necrosis factor [TNF] blockers, and I think the American College of Radiology, in their latest guidelines, called on them being first-line therapy. Do you want to tell us about TNF blockers?

Philip J. Mease, MD: Back in the years 1999-2000 when the first reports on TNF inhibitors were coming out, first in rheumatoid vasculitis, and then subsequently in psoriatic arthritis, it really was a sea change for us. Here we have a group of medicines that can lead to remission or low disease activity that can fundamentally change the trajectory of a patient’s life who has these diseases, so they have been very welcome workforces for us. They have adverse effect [AE] issues associated with their use, including the potential for a severe infection, rare risk or malignancy such as lymphoma, nonmelanoma skin cancer, and even rarer AEs like multiple sclerosis. The cost benefit has so much been on the side of the benefit that they have revolutionized what we do in our practices and what we can expect for our patients. When I see a patient for the first time, I’m letting them know that they’ve come along with this disease at a good time in terms of our ability to really impact it. It is very different than when I first entered rheumatology practice in 1982 when, believe it or not, our main treatment for these diseases was weekly injections of gold. We’ve moved beyond the alchemist stage, and we’re now into the stage of precisely targeting inflammatory molecules that leads to very good outcomes.

Mark Lebwohl, MD: You changed the way the world practices in psoriatic arthritis. You were the first author of that Lancet article, which showed that etanercept prevented the radiographic progression of joint disease, and that is a bar to which every drug ever since has been held. Everyone has had to go after and make those claims, and some of them cannot. We’ll talk about some of them coming up, but that really changed the way we practice. It’s interesting; in recent conversations, dermatologists still want to see that it prevents the radiographic progression of joint disease, and apparently, rheumatologists pay less attention to it, is what I was told at a recent meeting with my colleagues, but you know that the ones that can make that claim are the ones that work better.

There’s no other way about it. They work better for arthritis, not necessarily for psoriasis. So we move on now to ustekinumab, which actually is superior to many of the TNF blockers for psoriasis but never got to make the claim and prevents the radiographic progression of joint disease because, although it’s approved, it doesn’t work as well. Wouldn’t you agree?

Philip J. Mease, MD: The data would suggest that it doesn’t work quite as well as what we’ve seen with the TNF inhibitors and some of the newer agents, and so that is correct, but the safety profile is very good, and as you say, the psoriasis benefits are great. It’s very infrequent administration, but I think it has a definite place, and it can sometimes benefit, for example, if a person has coexistent inflammatory bowel disease. It can help them out, as well.

Mark Lebwohl, MD: Right, and I will say, when ustekinumab came out, we had patients on etanercept or adalimumab, for example, whose joints were fine. We didn’t even know they had psoriatic arthritis.Their psoriasis was not that well controlled. We switched them to ustekinumab; they clear completely, but had whopping arthritis, which was being suppressed by etanercept and adalimumab, and in many cases, we ended up having to switch them back because of the joints.

Transcript Edited for Clarity

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